FINAL BILL REPORT

SSB 6397

C 260 L 20

Synopsis as Enacted

Brief Description: Concerning nonparticipating providers.

Sponsors: Senate Committee on Ways & Means (originally sponsored by Senators Frockt, Rolfes and Keiser; by request of Health Care Authority).

Senate Committee on Health & Long Term Care

Senate Committee on Ways & Means

House Committee on Appropriations

Background: The 2011 Legislature passed SB 5927 to require the Medicaid-managed care plans to pay a nonparticipating provider no more than the lowest amount paid for that service under the managed care system's contracts with similar providers in the state. Nonparticipating providers must accept the amount paid by the managed care plan as payment in full, except for any deductible, co-insurance, or co-payment due from the enrollee.

The Medicaid-managed care plans must meet federal requirements to maintain a network of appropriate providers sufficient to provide adequate access to all covered services. The 2011 legislation required the Health Care Authority to monitor and report on the proportion of services provided by contracted providers and nonparticipating providers, by county, for each managed care plan to ensure the network adequacy requirements were met.

Prior to passage of the 2011 legislation, a Snohomish County Superior Court decision indicated a managed care plan should pay a non-contracted practitioner the full amount billed by the practitioner. There were estimates for significant impact to the managed care rates, and the state budget, if the ruling was applied statewide.

These provisions were to expire July 1, 2016.

The 2015 Legislature passed HB 1652 that required Medicaid-managed care plans to pay a nonparticipating provider no more than the lowest amount paid for that service under the managed care system's contracts with similar providers in the state if the managed care plan made good faith efforts to contract with the nonparticipating provider.

This legislation extended the expiration date to July 1, 2021.

Summary: The expiration date is removed that requires Medicaid-managed care plans to pay a nonparticipating provider no more than the lowest amount paid for that service under the managed care system's contracts with similar providers in the state, if the managed care plan made good faith efforts to contract with the nonparticipating provider.

Votes on Final Passage: